ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?
- A. Thyroid disease
- B. Allergy to penicillin
- C. Impaired liver function
- D. Abnormal blood glucose levels
Correct answer: C
Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.
2. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?
- A. A client’s wrist restraints tied to the bed rails
- B. A client’s bedside table placed across the foot of the bed
- C. A meal tray left at the bedside from breakfast
- D. A call light extension cord pinned to the bedspread
Correct answer: A
Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.
3. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
4. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?
- A. Ventrogluteal
- B. Deltoid
- C. Dorsogluteal
- D. Vastus lateralis
Correct answer: D
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.
5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. “Lie on your left side.”
- B. “Lie on your right side.”
- C. “Increase your fluid intake.”
- D. “Decrease your fluid intake.”
Correct answer: B
Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.
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